By requesting medication through PharmacyHealth.net (PharmacyHealth.net), I, the requestor, confirm the following truthful statements as if under oath and subject to penalties of perjury:

• I am an adult, capable of entering legal contacts, and at least 18 years of age.
• The laws in my geographical location permit the delivery of the requested medication(s).
• All questions asked of me during the medication request have been answered truthfully and completely.
• I will not distribute the requested medication(s) to others.
• I have had a recent physical examination by a local, licensed medical physician. Based on the results of my physical and medical history, my doctor has informed me that I should use the requested medication(s).
• I know that all medication(s) have associated risks. I understand that using and medication(s), including "over-the-counter" medication, has both benefits and risks.
• I will contact my local physician for and medical assistance in case I have any complications, issues, or questions regarding the requested medication(s).
• Knowing the risks associated with the requested medication(s), I consent to treatment.
• I will contact the prescribing physician and pharmacy immediately upon any complications, issues, or questions regarding the requested medication(s).
• I understand the benefits, side-effects, and risks of the requested prescription medication(s). I have read written and/or internet literature and have no additional questions.
• I have used the requested mediation(s) in the past while under a licensed doctor's care. I have been advised by my doctor that the requested medication(s) is proper for my immediate medical needs.
• I am requesting prescription medication for my own personal medical purposes.
• I request that a U.S. Licensed Medical Doctor assist my local Medical Doctor by prescribing the requested medication(s).
• I request the prescribing doctor to allow the fulfillment of the requested medication(s) by a licensed pharmacy.
• I do not request the prescribing doctor to replace the opinion of my local physician.
• I am requesting ONLY the needed amount of medication(s) for my condition and am not attempting to create a reserve, or stockpile of medication.
• I will not take any other medication(s), including "over-the-counter" medication, without prior approval from my pharmacist.
• I am the authorized cardholder of the credit card used for payment of the requested medication.
• I have provided ALL information concerning my health and medical history so that the pharmacist and prescribing doctor may properly review my request.

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